Improving Health for Mothers and Babies Through Care Coordination and Connection

“He’s a chatty little lad. Every time I see him he gets bigger and bigger,’’ she said to KaCee’s mom, TyiKalia Johnson. “I love seeing the baby grow up, especially after meeting him when he was in the NICU.”

Through ConnectRx, Ashford, who supervises UW Health’s clinic-based community health workers, will be part of Ty and KaCee’s lives up until his first birthday.

The ConnectRx Wisconsin program is an innovative model of care coordination that provides social determinants of health screening and support for qualifying pregnant patients and is funded in part by the Wisconsin Partnership Program.

Through a screening tool embedded in the electronic health record (EHR), health care providers and community health workers survey pregnant patients for social determinants of health such as housing, financial instability, food insecurity, transportation and stress. These factors can put their health, and the health of their babies, at risk. ConnectRx allows providers to make social prescriptions and integrates more than 1000 unique resources into the patients’ EHRs.

The screening alerted the ConnectRx team that Johnson, who went into early labor and gave birth at 30 weeks while visiting family in Wisconsin over the holidays, was essentially homeless in Madison. While KaCee, who weighed two pounds at birth, was in the NICU, Johnson was living in temporary housing, not wanting to go back to Florida and leave her baby behind. ConnectRx brought Johnson and Ashford together, and Ashford went to work finding stable housing for the family.

“She got me and baby a place to stay and basically held my hand through the whole process,’’ Johnson said. The relationship didn’t end with mother and baby in a new apartment. Recently, Ashford helped Johnson get furniture through a local charity and came to the apartment on the weekend to help her assemble it.

In the background, Ashford makes notes in Johnson’s electronic health records (EHR) so that Johnson’s, and her baby’s, care providers are aware of the social challenges they are facing.

This aspect of ConnectRx is crucial, said Ariel Robbins, MPH, ConnectRx program director. “It’s a benefit that so many of our community health workers have a clinical background, including backgrounds as certified nursing assistants or medical assistants, because they are literally writing documentation in the EHR so that others on the care team can see the issues,’’ Robbins said. “There are a lot of misconceptions about why people miss medical appointments or don’t take their medication. They may not have transportation, they may not have a place to live, they may not be able to afford their medication.”

Another member of the team, clinical health worker Justine Brown-Schabel agrees. “One patient was not taking her insulin, and it was because she didn’t have a refrigerator to keep it cold,’’ Brown-Schabel says. “Stress is a big factor in their health, and we can relieve them of some of the stress they are feeling.”

Brown-Schabel goes to medical appointments with clients, takes notes, types them up, and helps clarify communications between patients and providers. Other stress relief may involve getting diapers from a local diaper bank, obtaining a bus pass or finding a summer camp to keep older children cared for and occupied.

The clinic-based community health workers are part of a wrap-around system designed with input from more than 300 Black community members to reduce the health risks and support the social needs of people giving birth in the Madison area, with the ultimate goal of improving birth outcomes for Wisconsin’s mothers and babies.

ConnectRx is significantly strengthened by the inclusion of doulas, managed by the Foundation for Black Women’s Wellness. Under the leadership of Micaela Berry-Smith, the foundation’s senior program manager of community and maternal and child health initiatives, the collective of Well Black Doulas and community-based health workers provides exceptional support. Through ConnectRx care coordination, the standard of care includes anywhere from two to ten prenatal visits, comprehensive labor and delivery support, and from two to ten postpartum care visits, ensuring holistic and continuous care for the clients.

“We know the horrendous statistics: Black women are three to five times more likely to die in childbirth than white women and Black babies are three times more likely to die before their first birthday,’’ says Berry-Smith, a certified doula and mother of two. “So, to see a mother we care for make it through her pregnancy to the postpartum birthing suite – where mother and baby are surviving and thriving — this is the ultimate goal and there is no greater reward for our work than this.”

An early evaluation of the program showed it is making an impact. For the 20-month period beginning in April 2022, 90 percent of babies born with doula support reached optimal gestational age, and an impressive 84 percent were born at a healthy birth weight, addressing a critical factor in reducing Black infant mortality rates. Furthermore, in year one, 68 percent of clients avoided medical interventions, while an unprecedented 94 percent initiated breastfeeding, fostering healthy beginnings for mothers and babies alike.

During that time, 674 pregnant patients who were screened as high-risk were referred to ConnectRx Wisconsin for coordinated care, of which 600 were provided essential resources for housing, food, transportation and financial assistance.

Beyond the numbers, both groups of community health workers and doulas maintain close relationships with the families they’ve supported – attending birthday parties, providing support and celebrating milestones together.

Ashford says the health workers are often the first to get a call when parents or their children hit an important milestone.

“I love seeing where a family is now compared to when they were first referred to us,’’ Ashford says. “To see them go from being homeless to having stable housing. And being stable may mean that they can go back to school. This is not just a quick fix. As they gain stability, it can be life changing.”